My friend Abdi said, as I lay on his acupuncture table with a needle in my eye socket to release my then chronic migraine headaches: “It can be a cruel thing to let people get better at your own expense. It teaches them that they can only grow stronger by depleting you, and they will either learn to feel ‘better’ ruthlessly or, they just won’t get better at all.”

Working on the low-salaried front lines at what I called “the Big Box Store of Mental Health Services,” a heavily endowed “non-profit” agency for the formerly incarcerated severely mentally ill, I was sandwiched between the institutional violence that my clients withstood every day from the mental health/legal system, and my commitment to help them avoid committing personal acts of violence- a likely possibility if they weren’t extremely well cared for. I felt trapped in a masochistic position to my work and my profession.

The only way out seemed counter-intuitive: to take on more work. Since I had never negotiated or collected fees from clients, I decided to take a night job at a for-profit outpatient drug and alcohol rehabilitation center leading a 3-hour-long evening group (dear god, three hours) for sleepy-eyed drug-sick clients fresh out of detox. I confronted their resistances, manipulations, and evasions – and I eventually learned to successfully collect their urine and their $35 co-pays at the end of each night.

Next, I found a rent-by-the-hour therapy office, printed up business cards, and decided upon a moderate but self-respecting fee for a new therapist in private practice – which I planned on sticking to.

Almost all of the clients that first contacted me as a private practitioner were uninsured. Many of my first clients were sex workers, “exclusive” escorts, whose services were offered at very high prices. They referred many friends. And they paid my “full fee”, in freshly collected cash, which I accepted…squeamishly.

Another full fee referral stream came from a citywide foster care/group home agency: providing therapy for their at risk youth. I was amazed by the strength that these women and children could marshal in the face of horrible traumatic histories, and their ability to create change in their lives in light of the ongoing re-traumatization that they all faced.

It also became clear, on my end, that this was a terrible business model:

The kids aged-out of foster/group home care with no supports or any other reliable adults of any kind, and I suddenly had several totally overwhelmed traumatized young adults, with minimal burger joint incomes, doing their best to pay me a token $5 per session. Meanwhile, as the sex workers got healthier and stronger, they earned less in the “oldest profession” – as did I – as their fees shrunk to accommodate healthier and more self-regarding (and much lower-paying) work.

I was impressed and proud of the dramatic changes and the commitment to growth everyone had shown, proud of my own work – and I was just barely covering my expenses.

I hopped on an HMO insurance panel in an attempt to reach a new client base. I spent a very long 6-months, foisting the company’s financially mandated treatment “recommendations” onto our mutual clients: a business relationship which ended abruptly and forever one evening. A “care manager” determined, that from a cost perspective, Overeaters Anonymous would offer better support to a new client of mine: a 90-pound woman in recent anorexic relapse, following the diagnosis of a cancerous breast lump. She had, in previous years, a “high utilization” of her mental health benefits, which they were now deciding to cut off. After asking if they actually thought that a 90 pound woman sounded as if she had been over-eating, I resigned from the panel. I then negotiated a fee with my client that she and I could both, albeit barely, afford. I never signed a contract with any insurance company, ever again.

Money, money, money.

From this point forward, the only contract in the room, would be the one my clients and I negotiated together. I was worried, at first, that the gap between what I needed and what my clients needed would be irreconcilable. But – like a Quaker building consensus at business meetings – if you wait long enough, listen deeply enough to yourself and others, seemingly irreconcilable stances can find unity.

Here is what I knew:

When I let the client or the setting alone determine my value, I would be insufficiently reimbursed, injure myself, and set a destructive model for my clients.

I had also determined that setting fees based solely, rigidly on my own needs and desires was not realistic or sustainable for me. Abandoning clients in times of real financial crisis felt profoundly, spiritually and ethically, intolerable. It still does.

I needed to find a third way – not my perceived need alone or my clients’ perceived need alone. A way for money to become an extension, a true negotiation, of our mutual needs in the relationship. It struck me that there was a sacred fee, an optimum fee, that would need to emerge in the space between the client and myself, and perhaps this would be a different amount for each relationship. As relationships evolved and shifted back and forth, perhaps the fee had to as well. We needed to discover the healthiest amount for them to invest. The healthiest amount for me to receive, offering compensation for the inherent imbalances in the relationship, honoring and respecting all the needs of both people in the room.

It dawned suddenly, that talking money and negotiating fees was nothing more and nothing less than the exploration of the entire process of human relationship.

3 Comments

Supervising young social workers, psychologists, and psychiatrists in their early stage of practice building –
and watching them run the gauntlet of finances – moving from residency and agency supervision toward licensure and autonomous practice – keeps these associations fresh in my mind. Its takes time for everyone to discover how to think of money a natural healthy, liviing exchange in our relationships. Thanks, Robin, all of your support and incisive comments!

another really excellent post– i love the way you begin it– quoting your acupuncturist about how problematic, therapeutically, morally and personally (for the therapist) if patients get better by depleting the therapist. While there are many moments of depletion, a therapy relationship is ultimately healthy if both partners are enriched by it, and grow through it. Hard lesson to learn as a caregiver….
thanks–
Robin